Anatomy and Procedures

Head, Neck and Spine Abdomen

Upper Extremities Pelvis and Lower Extremities
Chest (Pulmonary and Cardiac) Lymph System

The protocols for the procedures listed may vary from institution to institution.
The procedure may be done differently than what is covered in this review.
Filming and injection rates may also vary. You should check with your institution
prior to performing any of the procedures so that you may follow their approved
protocol.

In Cardio-Vascular and Interventional Radiology, there are a large number of

procedures that you will assist with. For the anatomy and procedures section, we will
start from the head and work our way down. We will try to use as many x-rays as
possible to illustrate anatomy. These are brief reviews of the procedures, and all
procedures may not be covered. For each procedure listed we will cover indications,
contraindications, and risk of complication.

Head, Neck and Spine

Cerebral Angiograms (head and neck)

Indications: Contraindications:
Stroke Elderly Patients
TIA Contrast Allergy
Aneurysm Uncontrolled Hypertension
AVM Poor Renal Function
Tumor Coagulopath
Hemorrhage Severe Hemorrhage
Atheriosclerosis
Trauma
Subclavian Steal
 To perform a cerebral angiogram, you would access the
patient's artery (either femoral or brachial) using the
Seldinger Technique. The femoral approach is the most
frequent. If performing the angiogram for trauma,
atheriosclerosis, subclavian steal, stroke, or TIA, you would
first do an arch run. This is usually done with a pigtail
catheter positioned in the arch of the aorta.
This is done to see the anatomy of the arch and, if, for
trauma, we are looking for an aortic arch dissection. A 6 FR
pigtail catheter is commonly used for a trauma so that you
can get a big injection. After the arch run, you need to
exchange catheters. First, you would re-insert the wire
(common wires used here are the 3mm J or an LT). Once
the wire is over the arch you can remove your catheter. You
would then replace the pigtail with a Vertebral catheter. Or
if the carotids look difficult to access, you might use a
Simmons catheter. With the Simmons, you need to reform
the catheter in the aorta before you can selectively
catheterize the carotids.
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Care System
The first artery that you select is usually the one that is in question (but
it is not required to do that vessel first). After selecting the carotid
artery, you would leave your catheter just below the bifurcation. This
way you will get a good look at the carotid bifurcation before you put
any wires or catheters in it. For the best view of the bifurcation you
would usually do an LAO if you were in the left, and an RAO if you
were in the right. Because of some patients. vascular anatomy, you may
need to do the opposite oblique. You should always try to show the
vessels in more than one projection. We could also do a lateral run. This
is one of the best views of the carotid bifurcation. Some physicians may
also do an AP. All of these views will help to assess the amount of
stenosis.
After you have taken a good look at the bifurcation, you can visualize
the vessels in the head. If this were for a stroke or TIA, you would leave
the catheter where it is and do two views centered over the head (Towne
and Lateral). If you were doing this to look at an aneurysm, then you
would select either the Internal or External Carotid (usually the
Internal). If you have difficulty getting into the Internal Carotid, you
can use a coated wire (i.e. Glidewire) to help get your catheter into the
artery. Towne and Lateral views are done here also, but you need to do
additional views to "unfold" the vessels. Some additional views may be
a Transorbital Oblique, SMV, or Houghton.
Courtesy of VA Puget
 Sound Health Care
System
Towne Carotid Lateral Carotid
1. Internal 1. Internal
Carotid Carotid
2. 2. External
External Carotid
Carotid 3. Anterior
3. Choroidal
Anterior 4. Anterior
Cerebral Cerebral
4. Middle
Cerebral

Courtesy of VA Puget Sound Health Courtesy of VA Puget Sound Health

Care System Care System

A cerebral angiogram isn't complete until you look at the posterior circulation also.
Here you need to select one of the Vertebral arteries, whichever one looked easiest on
the Arch run. If you are unable to get into either Vertebral, you can leave your catheter
in the Subclavian artery. If you do this, you will need to put a blood pressure cuff up
on the same side that you are in (left Subclavian, left arm). The most common views
here are the Towne and Lateral, but you would be centered more over the back of the
head than the center.

Towne Vertebral Lateral Vertebral

1. Vertebral 1. Vertebral
2. Posterior 2. Posterior
Inferior Inferior
Cerebellar Cerebellar
3. Anterior 3. Basilar
Inferior 4. Superior
Cerebellar Cerebellar
4. Basilar 5. Posterior
5. Posterior Cerebral
Cerebral 6. Occipital
7. Posterior
Temporal
Courtesy of VA Puget Sound Courtesy of VA Puget Sound Health
Health Care System Care System
For patient positioning in cerebral angiography, you would basically keep the
patient's head in one position and move your imaging device. On the lateral views,
you would center your central ray just above the patient's ear in the center of his or her
head. If you were positioning for a lateral Vertebral artery, you would center slightly
lower on the patient's head (you want to include posterior circulation). On the frontal
views, for the Towne you would rotate your tube 15 to 20 degrees caudal. For the
Transorbital Oblique, the imager would be rotated caudal 15-30 degrees and LAO or
RAO 10-20 degrees. With the SMV, you would need to tilt the patient's head back as
far as possible and then rotate your tube caudal approximately 30 degrees. On the
Houghton view you would need to tilt the top of the patient's head toward his or her
shoulder and rotate the tube lateral (then move the whole c-arm oblique).

Complications

Since you have a catheter in the blood vessels feeding the patient's brain, you can
have some complications. If a piece of plaque is knocked loose the patient may have a
stroke or TIA, seizures due to a toxic chemical effect from the contrast media,
paralysis, vascular spasm, bleeding at the puncture site, hematoma, or death. All of
these complications are possible and not necessarily seen. But limiting the amount of
contrast, and the amount of time for the procedure, you will reduce the risks.

Injection Rates: Amount of Contrast

Arch 20-40 ml
Common Carotid 8-12 ml
Internal and External Carotid 4-9 ml
Vertebral 6-10 ml
Subclavian 8-15 ml

Filming Rates:
Arch Digital 3/3, 1/3-5
Common Digital or Cut 2/3, 1/10, .5/rest of
Carotid Film time

Artery Sizes (approximate,

average)-
Common Carotid 7-8 mm
Internal Carotid 5 mm
External Carotid> 4 mm
 Vertebral (one is
5-6 mm
usually larger)
Varies, can be up to
Subclavian
14mm

Besides diagnostic procedures, you can also do interventions in the head. With
interventions, the complication rate can rise drastically due to the disruption of blood
flow to the brain. Embolization can be done for AVM or tumors. Balloon Angioplasty
or stenting of Carotid or Subclavian arteries for stenosis. Thrombolysis can also be
performed for an occlusion (but extreme caution must be used so that you don't cause
bleeding in the brain).

Subclavian Steal Syndrome-

Flow is reversed in the Vertebral artery. This is caused from a blockage in the
Subclavian artery near the Vertebral artery. The blood is shunted past the brain
through the Circle of Willis and then to the Vertebral artery. The reverse flow in the
Vertebral artery fills the Subclavian artery. If looking for Subclavian Steal on the Arch
run, you should film out longer.

Circle of Willis
1. Vertebral 12.
2. Anterior Inferior Hypothalamic
Cerebellar 13. Anterior
3. Basilar Choroidal
4. Superior
Cerebellar
5. Posterior Cerebral
6. Posterior
Communicating
7. Middle Cerebral
8. Internal Carotid
9. Ophthalmic
10. Anterior
Cerebral
11. Communicating
Neuroangiographers also do spinal angiograms. These are not very frequent. They
are usually done to visualize the vascular supply to spinal tumors. On spinal
angiograms you would select each spinal artery, both left and right.

Myelograms-

Myelograms are usually done for stenosis in the spinal column. They are not as
frequent now because of MRI. Some surgeons still request myelograms for pre-op.
Two great guides on this subject are: How to do a Lumbar Myelogram and How to do
a Cervical Myelogram, both by Dr. Robert Dalley, Neuroradiologist UW Medical
Center. These guides are what the radiology residents receive on their neuroradiology
rotation.

Indications: Contraindications:
Tumors Recent lumbar puncture
Cord compression Papilledems
Nerve Impingement Increase cranial pressure
Spina Bifida Contrast reaction

The patient is placed on his or her stomach for a myelogram. Scout films are taken,
PA and cross table lateral for the lumbar myelogram. For a cervical myelogram you
need to take PA, cross table lateral and cross table lateral swimmers (this view is to
see C7 and T1). The puncture can be made lumbar or cervical. The lumbar puncture
can be done even if the patient is getting a cervical myelogram. The puncture is
usually made at L3-4 disc space. The spinal cord ends at L2. A local anesthetic is
injected at the puncture site prior to making the puncture with the spinal needle. The
spinal needle (usually 22g) is inserted into the patient's spinal column (in the
subarachnoid space). When you think that you are in the subarachnoid space, you
would remove your stylet and check for CSF (cerebral spinal fluid) flow. If you have
flow you can then inject contrast. If you don't have flow you can take a cross table
lateral view to check depth. You can also have the patient cough to see if you get flow
return that way.
If you have to do a cervical puncture, there are a couple of ways it can be done. If you
have a c-arm, you can have the patient lay on his or her stomach. Your puncture would
be behind and just below the ear (C1). If you don't have a c-arm, you would have the
patient lie on his or her side. After you have the needle in place, you would need to
log roll the patient unto his or her stomach. As you can tell, this type of puncture
carries more risk. If you do a lumbar puncture for a cervical myelogram, you would
need to place either shoulder restraints or ankle restraints on the patient. They will
need to be tilted head down to get the contrast into their cervical spine.

The contrast of choice for myelograms is non-ionic. The old oil based contrast is no
longer used. This decreases some of the risk factors for the procedure. With cervical
myelograms, you would use Isovue or Omnipaque 300, approximately 15-18cc. For a
lumbar myelogram, you would use Isovue or Omnipaque 180 or 200, approximately
15-18cc. Once the contrast is in place the physician will remove the needle and take
spot films. Some common views are AP, Lateral and multiple Obliques (steep and
shallow). After the physician is done with these films, you will need to take the same
films you took for scouts. With the lumbar myelogram, some physicians may require
you to do a conus view. This is where the spinal cord ends and it looks similar to a
cone shape (around L1-2). Usually AP and lateral views are done. If the patient is
getting a cervical myelogram, the head and neck will need to be hyper extended to
avoid contrast entering the head. This would cause a very intense headache.

After the myelogram, the patient should stay in bed for 4-6 hours. This is to make
sure the puncture site closes. After taking all of the overhead films, the patient will go
to CT for the rest of the procedure. In CT they will take images through the disc
spaces, usually 5cm cuts. By combining the myelogram with a CT, you get more
information for the surgeons.
 Complications
Nausea
Vomiting
Headache (most common)
Convulsions
CSF leak
Infection

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Upper Extremities

Indications: Contraindications:
A-V fistula (arterial
Contrast allergy
venous)
Trauma Poor renal function
Tumor Coagulopath
Uncontrolled
Aneurysm
Hypertension
Thoracic Outlet
Elderly
Syndrome
Occlusive disease

To gain access to the arteries in the upper extremities, you would either puncture
femoral or brachial using the Seldinger Technique (explained in Section 1). With the
femoral approach, the catheter passes through the Aortic Arch. With this approach you
need a longer catheter, approximately 100cm. A catheter with a slight angle works
well here, like a Vertebral or Headhunter. The catheter is usually left in the Subclavian
artery for most of the runs.
 1. Subclavian
Artery
2. Brachial Artery
3. Radial recurrent
Artery
4. Ulnar recurrent
Artery
5. Ulnar Artery
6. Radial Artery
7. Deep Palmar
Arch
8. Superficial
Palmar Arch
9. Digital Arteries

Care must be taken when injecting contrast because the patient may experience pain.
It is best to use non-ionics like Visopaque 320. A common injection rate for most of
the runs would be 5-20 cc. Filming is done in stations/steps, starting with the upper
arm (including the Subclavian artery/shoulder area). You will gradually work your
way down to the patient's hand. In some stations/steps you may need multiple views.
You can either rotate the c-arm or have the patient turn his or her arm. Filming can be
done either digital or with cut film. They both work well. Digital takes less time to set
up. Once you reach the patient's hand you will need to magnify to better visualize the
hand arteries.

Filming rate:
1 film/sec. for 5-6 secs., then 1 film every other sec for
about 8 secs.

Thoracic Outlet Syndrome-

The patient has arm pain, numbness, weak pulse, and decrease of blood pressure in
that arm, bruit, cold or blue hand. This is usually caused from a rib compressing the
Subclavian artery or vein. It can also be from abnormalities of the Scalene muscle,
vertebrae, or clavicle. Thoracic Outlet is a compression of the Brachial Plexus,
Subclavian artery or vein between the clavicle and first rib. Images are performed
with the arm in neutral position and hyperextended (in a position that is known to
cause the symptoms).
If performing the upper extremity angiogram for an A-V fistula (like problems with
dialysis) the fistula is stuck directly. Contrast can be hand injected or injected with an
injector. If the patient comes to you with needles inserted from dialysis, then hand
injecting is the best choice. If you have to access the fistula yourself then you may use
an injector. When you are planning on performing an intervention it is best to access
the fistula in the angio suite. Then you have a clean stick.

If indicated, you may have to do an intervention in the upper extremity. This may
include percutaneous transluminal angioplasty, stenting or thrombolysis. These would,
of course, depend on the indications and the findings from your angiogram.

Complications
Catheter malposition
Stroke
Occlusion
Spasm
Nerve Root damage

Venogram-

Indications: Contraindications:
Edema Contrast allergy
Trauma Poor Renal function
Tumor Coagulopath
SVC Obstruction Uncontrolled Hypertension
Elderly

For an upper extremity venogram, you would access it distally with a small butterfly
needle (19 or 21 g). After the needle placement, test inject with saline to make sure the
needle is positioned correctly in the vein. When injecting in the venous system, hand
injections work well. Digital is easier to control. A common complication would be
extravasation of contrast.

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Chest

Pulmonary Angiogram-
 Indications: Contraindications:
Suspicion of Pulmonary
Recent MI
Embolism
on VQ Scan Contrast Allergy
Pulmonary Left Bundle Branch
Hypertension Block
Pulmonary
AVM
Hypertension
Tumor Coagulopath
Elderly

To look at the pulmonary arteries you need to puncture (gain access) through the
venous system. There are several ways to gain access for a pulmonary angiogram. It
can be done through the upper extremity (right), femoral or jugular veins. With the
femoral approach, it will be easier to select the pulmonary arteries.

Prior to the pulmonary angiogram you need to make sure that the patient does not
have a left bundle branch block. To get to the pulmonary arteries, you need to pass
your catheter through the right side of the patient's heart. If they have a left bundle
branch block you will cause a complete heart block. The catheter of choice for most
pulmonary angiograms is the Grollman or Van Amen pigtail.

With most pulmonary angios you will look at both sides of the lungs. The right lung
has three (3) lobes and the left lung has two (2) lobes. AP and oblique views are done.
An LAO or RPO view for the left lung (30-45 degrees). An RAO or LPO (10-15
degrees) for the right lung.

Right Pulmonary Arteries Left Pulmonary Arteries

 1. Right 1. Left
Main Main
PulmonaryPulmonary
2. Basilar 2. Basilar
Segmental Segmental
Branches Branches

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Care System Care System

Catheter travel (Femoral approach)-

The catheter passes up the IVC (Inferior Vena Cava) into the right atrium through the
tricuspid valve into the right ventricle, to the pulmonary valve and into the pulmonary
artery. When manipulating the catheter you need to watch the patient's EKG. The
catheter movement through the heart may cause abnormalities.

Usually, prior to each injection of contrast, pulmonary pressures are taken. It is a

good idea to do these prior to the run just in case the catheter "kicks" out on
injections. Pulmonary artery pressures average 8-25 mmHg with a mean of 13 mmHg.
The contrast injections are between 30 and 50 ml. Filming is 2 to 4 frames/second for
4 seconds and then 1 frame/second out at least 4 seconds or more.

Filters-

If a PE (pulmonary embolism) is seen, the patient's physician needs to decide if the

patient should be anticoagulated or have a filter placed. If the decision is to use a
filter, a Vena Cavagram is done to see where the patient's renal veins are and to assess
any clot in the iliac veins. It is important to know where the patient's renal veins are so
that you do not cover the opening with the filter. For ease of placement a ruler can be
placed under the patient prior to the Vena Cavagram. You can then look at the position
of the renal veins and the corresponding number on the ruler.

The filter may be placed suprarenal or infrarenal (above or below the renal veins). If
the patient has a duplicated cava, then you would want to place the filter suprarenal. If
the patient has a known clot in the iliac veins, you can place the filter with a jugular
approach. There are a variety of filters available (see the equipment and supplies
section for types of filters). Filters come loaded differently for femoral and jugular
approaches. If you place a jugular filter femorally, the filter will be upside down and
will not be effective. It is important to read the label closely. A jugular Bird's Nest
filter can be placed femorally because of the design and shape of the filter. If the
introducer were long enough, you could place the femoral Bird's Nest filter jugular.
However, in most cases the catheter is too short.

Complications
Cardiac Related
Air Emboli
Blood Clot knocked loose
Infection
Occlusion
Filter Migration

Cardiac Cath-

Indications: Contraindications:
Angina Congestive Heart Failure
Highly Positive Excerise Tolerance Test Hypertension
Pre-OP Evaluation Hypokalemia
Silient Ischemia Arrhythmias
Coronary Spasm Infection
Atypical Chest Pain Electrolyte Imbalance
Recurrent Symptons post Bypass Anemia
Valvular Heart Disease Stroke
Congenital Heart Disease Fever
Cardiomyopathy Contrast Allergy
Heart Transplant Renal Insufficiency
Elderly
Cardiac catheterization is done using either the brachial or femoral approach. The
brachial approach is also known as the Sones. It was originally done with a cutdown
at the antecubital, but it may also be done with a percutaneous approach. The femoral
approach is also known as the Judkins. This is most commonly used for left heart
catheterization.

Left Heart Cath- Right Heart Cath-

The catheter is introduced arterial.
The catheter is advanced through
the aorta into the left ventricle
Indications:
Coronary Artery Disease
Myocardial Ischemia (MI)
Cardiomyopathy
Congential Heart Disease
Transplant
The catheter is introduced venous.
Usually used to measure pressures
(endhole or Swan-Ganz Catheter).
Indications:
Congestive Heart Failure
Valvular Disease
Cardiomyopathy
Pericardial Disease
Right Venticular Dysfunction

*For hemodynamic pressures see Section 3- Patient Care.

Since the heart is always moving (and you can't hold it still by having the patient
hold his or her breath) you need to film it at a high speed. For Cardiac Cath Cine is
used. Most cardiac filming is done at 30 frames a second.

Filming-

Right Coronary Artery

LAO 45
To profile Right Coronary Artery
body

RAO 30
Profiles Posterior Descending and
allows identification of Conus and
SA node branches

LAO 45, CR 30 Cranial

Posterior Descending and Right
Coronary Artery bifurcation and
distal branches
Contrast Injection- 2-3 cc/second for a total of 4-8 cc

Left Coronary Artery

PA/AP
Left Main, Mid Left Anterior
Descending and Circumflex

RAO 10
Left Main, Mid and Distal Left
Anterior Descending and Distal
Circumflex

RAO 30
Mid and Distal Left Anterior
Descending, Mid and distal
Circumflex
 RAO 30, CR 30 Caudal
Left Main, bifurcation of Left Main,
Proximal Circumflex, Proximal
Left Anterior Descending, Mid
Circumflex

RAO 30, CR 30 Cranial

Seperates Diagional from Left
Anterior Descending
 LAO 45
Mid to Distal Left Anterior
Descending, seperates Diagional
from Left Anterior Descending

LAO 45, CR 30 Cranial

Bifurcation Left Main, Left
Anterior Descending seen well

Caudal 30
Left Main bifurcation, entire
Circumflex, Obtuse Marginal
Cranial 30
Left Anterior Descending elongated
Contrast Injection- 3-4 cc/second for a total of 6-10 cc

Venticulogram-

Right Ventricle Left Ventricle

 Done for right to left shunting, pulmonary Septal defects, mitral
stenosis, tricuspid regurgitation, regurgitation. Pressure
pulmonary outflow measurements
Injection- 12-15 cc/second for
Injection- 15 cc/second for 50cc
35-50 cc

Root Injections-

These injections are done for the following indications: Aortic Valve regurgitation,
Ostial lesions, to evaluate coronary grafts, and dissecting aneurysms. When injected,
you will see both the left and right Coronary Arteries.

Complications:
Myocardia Ischemia (MI)
Death
Vascular Injury
Stroke
Vasovagal Reaction
Cardiac Perforation
Arrhythmias
Infection

Percutaneous Transluminal Coronary Angioplasty (PTCA) or Stenting-

Pressures are taken prior to and during PTCA. The patient is anticoagulated to
prevent blood clots from forming. The patient must be monitored carefully during
balloon inflation. If the stenosis isn't improved with balloon angioplasty then a stent
may be placed. The stent is mounted on a balloon catheter and placed the same way
that you would perform a balloon angioplasty.

Valvuloplasty-

Stenotic valves can also be balloon angioplastied like PTCA, except that the balloons
are much larger, stents are not used, and the re-stenosis rate is very high.

Endomyocardial Biopsy-

Indications:

Transplant
 Viral Myocarditis

Malignancies

Fibrosis

The biopsy catheter is advanced into the Right Ventricle through a guiding catheter.
The biopsy catheter is then advanced out of the guiding catheter and a tissue sample is
taken from the septal wall.

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Abdomen

Aortogram-

Can be done with a Runoff (Femoral Angiogram), Renal Angiogram or Visceral

Angiogram.

Contrast Injection: Filming: 2 films a second for 4 seconds then

20-40 ml 1 film a second for 3 seconds then
1/2 film a second for 20 seconds

Renal Arteriogram-

Indications: Contraindications:
Renal Mass Renal Failure
Hypertension Pulmonary Edema
Renal Artery Stenosis Hypertension
Trauma
Aneurysm
AVM
Kidney Donor

A renal arteriogram may be done with either a femoral or an axillary approach. The
femoral approach is more popular. A multisidehole catheter (pigtail catheter is most
common) is advanced up the aorta and positioned with the sideholes just above the
renal arteries (usually L1). AP and Oblique views (to rotate the renal artery origins off
the spine) are obtained. The renal artery can be selectively catheterized for
intervention (PTA, stenting or embolization) with catheter shapes like the cobra or
RC2.

If an intervention were going to be performed (like embolization done for pre-kidney

removal for transplant or for renal mass) then you would advance the catheter into the
renal artery or a branch off the main renal artery. This may also be done for aneurysm,
AVM or trauma. Once you have selected the area to be embolized, then you can
deploy your embolization material. For trauma it is common to use Polyvinyl alcohol.
You may also embolize with gelfoam or coils.

If the intervention is for stenosis, then you will need to cross the stenosis with a wire.
Once you cross the stenosis you should leave something (like the wire) across for the
whole procedure. It is common to have spasm here. With the wire across the stenosis
you will still be able to get your balloon, or stent, across. Prior to the angioplasty, the
patient should take 10mg of Nifedipine orally. You can also place an inch and a half of
Nitropaste on the patient's chest. You should also have some Nitroglycerine mixed just
in case you have spasm. Some lesions may be stented directly instead of PTA first.
After the PTA, the patient should be monitored closely to watch his or her blood
pressure. It may drop because of the increased blood flow to the kidney. Some
institutions require the patient to go to the intensive care unit overnight.

AP
Aortogram
1. Celiac
2. Renal
Arteries

Courtesy of VA Puget Sound Health

Care System

One of the newer procedures being performed is the Stent Graft. This is an
endovascular repair of the artery, usually an aneurysm. This procedure is still
relatively new and has not been started in many institutions. The cost and time to get
the institution set up for these procedures can be expensive. Many of the institutions
are remodeling, and replacing angiography equipment at the same time, so that they
can do these procedures. The angio suite needs to be setup as an operating room for
the procedure. If the room is not setup that way, some institutions are performing the
procedure in the operating room with portable c-arms. As you can guess, this is not
optimal. Prior to having an AAA stent graft placed, that patient needs to be worked up
for the procedure. The patient needs a recent CT that documents the aneurysm and
will need to get an angiogram. You may hear the angiogram referred to as a calibrated
angio. Certain images are required to determine if the patient is a candidate for this
procedure and to measure the inside of the aneurysm.

When an aortogram is done, usually about 30 ccs of contrast is required to fill the
aneurysm sac. A typical pigtail catheter is not used here; a calibrated or graduated
sizing pigtail catheter is used. This catheter has measuring beads along the shaft in
5mm and 1mm increments. After acquiring the AP view, a spot film of the lateral is
done. This is to measure the angulation of the aorta. A lateral view with contrast can
also be done, if needed, for the visceral arteries to check for patency. The catheter
should then be pulled down and an AP and both obliques of the pelvis are done. A
lateral view of the pelvis is needed to also check the angulation. This should be done
with the catheter in the same position as the AP. If the iliac arteries are torturous then
you should perform a guide wire test. This is done by putting a superstiff guidewire in
and taking a spot film to see how well the arteries straighten.

With some patients, their aneurysm may extend into the internal iliac arteries and it
may be necessary to embolize them prior to the stent graft procedure. This is to help
with sealing the graft so that the aneurysm doesn't fill from the internal iliac arteries.
After all of the films have been taken, and any arteries embolized, the patient can be
taken off of the angio table. The interventional radiologist will review the films and
take special measurements. These measurements will determine what size stent grafts
are needed. All of the necessary supplies are ordered and the patient is scheduled for
the procedure. The supplies that you need with depend on the brand of stent graft you
are using. You will get a list once you get on a protocol with one of the companies.

The room is surgically prepared if the angio suite is used to place the stent graft. An
anesthesiologist will sedate the patient. The sedation commonly used is a spinal, or
epidural. Some anesthesiologists may be more comfortable with a general anesthetic.
Because of the size of the introducer that the stent grafts come on, a cut down is
needed on both groins. This is done by the Vascular Surgeon, who will be assisting
during the procedure. Once access is gained, the interventional radiologist will
reconfirm the positioning for the stent graft. After determining that the position is
correct, the stent graft will be deployed. You will bring a wire through the opening
from the other groin for the limb of the graft. Once you are sure that the wire is inside
of the graft, you will deploy the limb of the graft. An aortogram is done to check for
filling of the aneurysm. If the aneurysm still fills, then you will need to determine if it
is filling from the top or bottom end. You may need to angioplasty the ends or place
an extender cuff. Once the aneurysm no longer fills, you are finished and the patient is
followed up with CT.

Fibromuscular Dysplasia (FMD)-

Fibromuscular Dysplasia is the cause of hypertension in one-third of hypertensive

women. It is usually found in the branch arteries and responds well to angioplasty.

Complications:
Spasm
Emboli

Visceral Arteriogram-

Indications: Contraindications:
Mesenteric Ischemia Elderly Patients
Aneurysm Contrast Allergy
Uncontrolled
AVM
Hypertension
Portal Hypertension Poor Renal Function
Intestinal Angina Coagulopath
Mesenteric
Thrombosis
Vascular Injury
Tumor
Bleeding
 1. Celiac
(found
around
T12-L1)
2. Splenic
3. Hepatic
4. SMA
(found
around L1)
5. IMA
(found
around L2-
Courtesy of VA Puget Sound Health L3)
Care System

An aortogram is performed, usually AP and Lateral. The lateral is done to see the
origins of the visceral arteries (Celiac, SMA, and IMA). An oblique view may be
required to see the origin of the SMA (superior mesenteric artery). PTA may be
performed if there is a stenosis in the mesenteric arteries (SMA or IMA). But many
visceral angiograms are done because of GI bleeding, and you may be required to
embolize if you see the bleed. Embolization is usually done with coils and gelfoam in
the visceral arteries. You would, of course, want to select the vessel feeding the bleed
first.

Complications:
Infection
Bleeding
Thrombosis
Spasm

Transjugular Intra-Hepatic Portal Systemic Shunt (TIPS)-

Indications: Contraindications:
Portal Hypertension Coagulopathy
Bleeding Varicies Elderly
Ascites Liver Failure
Cirrhosis
You would use a transjugular approach here. After getting access into the patient. s
Internal Jugular vein, you would pass your catheter down the Vena Cava into the
Hepatic vein. Once in the Hepatic vein, you can do a Wedged venogram and measure
pressures. Normal Wedged pressure is 5mm. The Wedged venogram is to see the
patient's portal system to check if it is open. Once you have the venogram, you can
advance your needle through the hepatic vein into the liver parenchyma and into the
portal vein. Once you are in the portal vein, you can advance your wire and then dilate
and stent your shunt. The patient should have routine follow-ups with ultrasound after
this procedure to monitor the shunt for patency.

Complications:
Hemorrhage
Thrombosis

Percutaneous Abscess Drainage-

Indications: Contraindications:
Increased WBC Location
Fever Size
Walled off Abscess seen on
Coagulopathy
CT

The patient may need to be aspirated or have a drainage catheter placed. If the area is
small, and the requesting service wants to check for infection first, you can just
aspirate it and send a sample to the lab. If they want a catheter placed, you can do this
in CT. One advantage of placing the catheter with CT guidance is that you can see the
path of the needle as you advance it to make sure you don't place the catheter through
an organ.
If you are placing a drainage catheter, the patient should be on antiobiotics. A needle
is advanced into the abscess, checking with CT to make sure you are in the correct
space. You should use a large needle, like an 18g, so that you can place a .035 or .038
wire. This will make advancing the catheter easier. Once you are in the abscess, you
can advance lots of wire into the space and remove your needle. You can then insert
the catheter over the wire into the space. The catheter should be locked, or sutured, in
place and a sample taken. The abscess should be aspirated and flushed well after
placing the drain. Some of the abscess material may be thick and by flushing you will
help loosen it up. The Interventionalist should see the patient each day on the floor
and make sure the abscess is draining well. When the drainage stops, or is less than
10cc a day, you should have the patient come down for a sinogram.

Complications:
Infection
Bleeding
Septic Shock
Fistula

Percutaneous Biliary Drainage-

Indications: Contraindications:
Malginancy Acities
Biliary Obstruction Advanced Cirrhosis
Cholangitis Hepatic Metastises
Stones Liver Failure

The patient should be on antibiotics prior to this procedure. The patient should be
placed supine on the table with the right arm above the head. For a right-sided
puncture, you would insert the needle 2cm posterior to the midaxillary line at the
eleventh intercostal space. Ultrasound may be used during placement. The needle
should be 21 or 22g. This will cause less bleeding. Once you get bile return, you can
inject contrast to see where you are in the biliary system. You will likely need to
reposition to get better access to the biliary duct. For catheter placement, leave your
needle in place and use a second needle to get into better position. Once you are in
good position you can advance a wire and remove the needles. Your catheter will be
placed over the wire and, if you are going to put this patient on internal and external
drainage, you should advance your catheter to the duodenum. This will give you better
drainage. If the patient has a stricture in the biliary system, you can dilate this during
catheter placement. You may also need to stent it. The stricture is usually due to a
tumor compressing the biliary system. If the patient has a tumor, it may grow through
a stent.

Complications:
Sepsis
Hemobilia
Cholangitis

Peritonitis

Courtesy of VA Puget Sound Health

Care System

If the patient has stones in his or her biliary system, you may be required to retrieve
them with a basket or snare. Biliary drainage procedures are less frequent these days
because many of the patients can be done with an ERCP.

Percutaneous Nephrostomy-

Indications: Contraindications:
Kidney Obstruction Bleeding
Hydro
Stones

The patient should be placed on the table prone with the side of interest up. If this
were because of stones, then you would access an upper pole calyx. Otherwise, you
can access a middle or lower pole calyx. To gain access, you can use an access set like
the accustick set from Boston Scientific. And you can use ultrasound guidance during
catheter placement. The needle is advanced into the calyx. Air and contrast can be
injected to check positioning. Once you are in good position, you can advance your
wire and place your catheter. If the patient has a ureteral stenosis you may need to
place a ureteral stent, either a nephroureteral or a double J. A double J stent is
completely internal. One J is in the bladder and the other J is in the kidney. The
nephroureteral stent has a pigtail in the bladder; a locking loop in the kidney, and the
end of the catheter exits the skin. If the patient has stones, we sometimes do this
catheter placement prior to PUL (percutaneous ureteral lithrotripsy). In that case, you
would also need to leave a catheter in the bladder in addition to the catheter in the
kidney.

Complications:
Hematuria
Hemorrhage
Infection
Peritonitis

Extravasation

Courtesy of VA Puget Sound

Health Care System

Percutaneous Gastrostomy-

Indications: Contraindications:
Long Term
Gastric Outlet
Feeding
Esophageal
Gastroesophegeal Reflux
Obstruction
Enlarged Liver
Prior Sugery with removal of part
of the Stomach

The evening prior to the gastrostomy tube placement, the patient should drink
approximately 500cc of thinned down barium. This will help visualize the colon. If
the patient is unable to drink due to an obstruction, an NG tube should be placed and
the barium given via the catheter tube. Be sure to flush the tube well after this
procedure. When the patient comes to the angio suite the next day, they should have
IV access and a NG tube. Once the patient is on the table you can ultrasound to see
where the liver border is. You should fluoro the patient to see if the barium is in the
transverse colon. If the barium has not reached the transverse colon, you can give the
patient a barium enema on the table. The barium should be thinned down because you
want to be able to see through it during the procedure. This procedure can also be
done without barium by placing the catheter under CT guidance.

Percutaneous
Gastrostomy
Anatomy-

1. NG tube
2. Gastrostomy
tube
3. Contrast in
Stomach
4. Large Intestines

Courtesy of VA Puget Sound Health Care System

Once you have the patient prepped and draped, you should inflate the stomach with
air. This will distend the stomach, giving you a better target. Glucagon can be given to
slow peristalsis. Stay sutures can be used to keep the stomach up against the
abdominal wall. This will keep the stomach from pushing away when you insert the
catheter. The stay sutures are on a needle. You would numb the site and insert the
needle into the stomach. You should pull back on the syringe on the needle to see if
you get air back. That will be a good indication that you are in the stomach. Contrast
can also be injected to see if you have rugae. Once you have all the stay sutures in
place you would insert your needle, check to see if you are in the stomach, and place a
wire. The type and size of catheter will determine what we do next.

If you have a hydrophilic catheter, you may be able to insert it without first dilating
the tract. There are a couple of different ways to dilate the tract. You can use serial
dilators or you can use a high-pressure balloon (like a Blue Max). After the tract is
dilated, a sheath is inserted. Some needles have a teflon sheath on them and you
would not need to use another sheath. The catheter is inserted through the sheath. To
help the catheter through the sheath you should slick it up with gel. Once the catheter
is in the stomach, you can peel the sheath away and lock the catheter in place. This is
done with either a balloon or a locking pigtail. The catheter can also be sutured in
until the tract matures. The NG tube is removed, and the catheter should be placed to
drainage until the next day.

Complications:
Puncture of liver or colon
Placement of catheter in abdominal
cavity
Bleeding

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Pelvis and Lower Extremities

Indications: Contraindications:
Ischemic Leg Renal Failure
Gangrene Contrast Allergy
Rest Pain Uncontrolled Hypertension
Claudication Bleeding Disorders
Trauma
Aneurysm
Tumor
AVM

Gain access with a Femoral or Axillary approach and advance the catheter to the
aortic bifurcation. A pigtail catheter is usually used to visualize the arteries in the
pelvis. If you are going to look at both legs, it is a good idea to do oblique views of
the pelvis first and save the AP view for the runoff. LAO (RPO) and RAO (LPO)
views are done. The two obliques will help to lay out the internal and external iliacs.
If both legs are being done, the catheter can be left at the birfurcation and the injection
can be done from there. Lower extremity runoffs can vary on filming by each
institution. Most are done as a digital runoff (the table will move and as you are doing
the run you can see what is happening) or cut film (the table will move in
stations/steps and you won't be able to see the films until you run them in the
darkroom).

The digital runoff can be done automatic or interactive. With the automatic, you
would do a run timing how long it takes for the contrast to reach the knees. You would
then put that number into the settings, and the program will move the table in
accordance with the settings. If it is interactive, you can control when and how fast the
table moves. That way, if the contrast slows down when it hits the trifurcation, you
can slow the table down. One way to help the flow of contrast is by placing a heating
pad on the patient's feet prior to the runoff. This will increase circulation. If the patient
has gangrene or open sores, then a heating pad is not indicated.

Injection Amount of
Rates: Contrast
Pelvis 10-15 ml
Runoff
single leg 50-60 ml
bilateral 80-100 ml

Filming
Rates:
2/3-4, 1/6-10, .5/rest of
Pelvis
time
varies- with interactive
Runoff
you control it

Artery Sizes(approximate, average)-

Common Iliac 8-12 mm
Internal Iliac 6-8 mm
External Iliac 6-10 mm
Femoral 6-8 mm
Trifurcation Vessels 3-6 mm

On the lower extremities we can also perform interventions. Some common

interventions are thrombolisis, percutaneous transluminal angioplasty, stenting, and
embolization. Thrombolisis is indicated when the patient has a cold pulseless
extremity. PTA and stenting are indicated when the patient has a stenosis or occlusion.
Embolization is indicated when the patient has a vascular tumor or AVM.

Pelvis and Lower Extremities

Pelvis-
1. Aortic
bifurcation
2. Common
Iliac Artery
3. Internal
Iliac Artery
4. External
Iliac Artery

Courtesy of
VA Puget
Sound Health
Care System
Thighs-
1. Femoral
Artery
2. Deep
Femoral
Artery

Courtesy of
VA Puget
Sound Health
Care System

Distal
Thighs-
1. Femoral
Artery
2. Stenosis

Courtesy of
VA Puget
Sound Health
Care System
 Knees-
1. Popliteal
Artery
2. Anterior
Tibial Artery
3. Peroneal
Artery
4. Posterior
Tibial Artery

Courtesy of
VA Puget
Sound Health
Care System

Embolization-

Embolization can be performed on vascular tumors, AVM, or aneurysms. There are

several types of embolization materials available (see equipment and supplies
section). In the lower extremities you might use coils and gelfoam. You would
selectively catheterize the vessel to be embolized. If it is a small vessel, you may need
to use a tracker catheter. After placing your embolization material, you would wait a
few minutes and then do an injection to make sure it is occluded.

Percutaneous Transluminal Angioplasty and Stenting-

 Image of an Iliac angioplasty
In this image the balloon is inflated. As you
can see the wire is positioned so that is stays
above the lesion. That way if the PTA fails
then you still have access. After PTA the
blood vessel can spasm down.

Courtesy of VA Puget Sound Health Care

System

This is an image pre PTA

In between the radiopaque beads is the
balloon catheter and you can see where the
stenosis is.

Courtesy of VA Puget Sound Health Care

System
 This is a post PTA/stent image
This is the same patient as below, but filmed
with contrast. You can see how smooth the
vessels look with the stents in place.

Courtesy of VA Puget Sound Health Care

System

This is an image post stent placement

If you look carefully at the image you can
see stents in both Iliac arteries. The
radiopaque beads that you see in this image
are the sheaths.

Courtesy of VA Puget Sound Health Care

System

Prior to performing an intervention, you should check with the Vascular Surgeon.
Some stenosis are best for intervention and some need surgery. Pressure measurement
can be taken to determine if there is a large enough gradient to warrent PTA. Pricoline
can be given to simulate activity. The wire should be advanced past the stenosis and
the balloon or stent advanced over the wire. After PTA or stenting, the wire should be
left past the stenosis, and an injection should be done to check for residual stenosis.
You might need to PTA again. If the vessel spasms you can inject nitro, but if you wait
a few minutes the spasm may go away on it's own.

During PTA the pressure of

the balloon cracks the
plaque and stretches the
wall of the artery out. You
may need to inflate several
times to get the artery open.
If PTA fails then you can
place a stent. The stent
works in the same way as
the PTA. The plaque is
cracked and the wall of the
artery stretched. It is very
important during PTA or
stenting that you measure
the size of the artery first.
You may risk tearing the
artery and cause the patient
to go to emergency surgery
to repair the burst artery.
You should also ask the
patient how much pain they
are having on a scale of one
to ten. This will give you an
idea of how well the artery
is responding to PTA. If the
patient says that the pain is
a four, then you will need to
PTA again. If it is a ten, then
you should check and see
what kind of results you got.

Sometimes patients come in with a cold pulseless extremity, so we evaluate their

arteries. We may need to infuse medication to re-open their arteries. Some common
causes of occlusion are tight stenosis, plaque breaks free and migrates, graft
occlusion, and trauma. If a patient has had recent major surgery within the past 2
weeks, thrombolisis should not be performed. Another contraindication is head injury
or Subdural bleed. The catheter is advanced as close to the occlusion as possible, and,
if possible, into the clot. An infusion catheter is left in place, either one with multiple
sideholes or just an endhole. Heparin and Urokinase or TPA can be infused through
the catheter. Usually the Urokinase or TPA will go directly into the clot and heparin
with go through a sheath or IV. The patient will need to go to an intensive care unit
until the infusion is completed. The patient should return to the angio lab a couple of
times a day to check the progress. The catheter may need to be repositioned. It is not
uncommon for an infusion to go from 1 day to a week.

Thrombolisis-

Complications:

Bleeding
Distal Occlusion
Hematoma
Spasm
Infection

Pre thrombolisis Post thrombolisis

Courtesy of VA Puget Sound Health Courtesy of VA Puget Sound
Care System Health Care System

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Lymph System

Lymphangiogram-

Indications: Contraindications:
Neoplasm or
Intracardiac shunt
Lymphoma
Enlarged Nodes Pulmonary Disease
Radiation Therapy to the
Staging
lungs
Leak
 A blue dye is injected between the toes to locate
the lymph vessels (Methylene Blue or
Lymphazurin). It may take up to 15 minutes for the
lymph vessels to pick up the dye. Once you can see
the lymph vessel, you will need to cut down to
access it. This may be unilateral or bilateral. The
lymph vessel should be lifted out slightly to isolate
it and then canalized with a small lymph needle
(27g). It is a special needle with tubing connected to
it. Once you are in the lymph vessel, you can inject
a small amount of contrast to test needle position.
The tubing is connected to a glass syringe in some
type of holder. The syringe is filled with the
contrast - ethiodol (poppy seed oil). This contrast
will eat through plastic. You need to use glass
syringes and, if using any stopcocks, they need to
be metal.
Once you connect to the syringe, lead weights are
placed on the top of the plunger and the contrast is
injected by gravity. If you inject too quickly, you
can blow the lymph vessel. Some physicians like to
suture the needle in place so that it doesn't fall out.
Ethiodol works best when warmed, so it is a good
idea to have some type of light up next to the
syringe during the injection. Approximately 10cc
are injected and this may take up to an hour.
If this is being done for staging, then you will take
overhead films of the lower leg(s), pelvis, abdomen,
and chest. You will take these films again in 24
hours. This is not done much these days because
with CT you can stage the lymphoma more quickly
and be less invasive. If this is to visualize a leak in
one of the ducts, you could just fluoro the contrast.
When it is in the right spot take the patient to CT.

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Copyright 2000 Leona Benson